A Duplex scan is an ultrasonic scanning procedure used to characterize the pattern and direction of blood flow in arteries or veins with the production of real-time images. While duplex ultrasound is a relatively safe and widely available modality it does have its particular shortcomings and specific indications.

Obtaining a high quality study requires the interplay of a number of factors. There are established criteria that are important to consider in order to ensure reliable, interpretable and meaningful results. Renal Artery imaging involves the use of color Doppler to access flow disturbance and the presence of plaque and spectral Doppler to measure flow velocities from the renal artery ostium to the hilum. Doppler spectral waveforms are obtained from the segmental arteries of the renal parenchyma. Kidney length is noted. Multiple renal arteries are noted. Patency of the renal veins and any other abnormalities such as masses or cysts are documented.

A review of common clinical scenarios where cerebrovascular ultrasound is used follows. These scenarios are scored for appropriate use on a scale of 1-9. A median score of 7-9 indicates that this is an appropriate test for the specific indication. A median score of 4-6 indicates that there is unclear evidence as to the appropriateness of the test. A median score of 1-3 indicates that the test is not generally acceptable for the indication.

Indications

This procedure is indicated in the evaluation and/or management of vascular disease involving vessels of the abdominal, pelvic, scrotal contents, and/or retroperitoneal organs.

Limitations

Duplex scanning in the evaluation of an abdominal aortic aneurysm is of limited value unless there is a pulsatile abdominal mass and signs and symptoms of peripheral vascular disease are present.

Noninvasive vascular studies are medically necessary only if the outcome will potentially impact the clinical course of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of noninvasive studies, noninvasive vascular procedures are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.

The accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skills and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation of such for possible audit. Further, noninvasive vascular diagnostic studies must be either (1) performed by persons with appropriate training that have demonstrated minimum entry level competency by being credentialed by a nationally recognized credentialing organization in vascular technology (e.g., American Registry of Radiologic Technologists (ARRT) in vascular technology), (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in vascular technology.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999xNot Applicable

Revenue Codes:Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Aorta, inferior vena cava, iliac vasculature, or bypass grafts (procedure codes 93978 and 93979) Connecticut and Florida Medicare may provide coverage for duplex scanning of aorta, inferior venacava, iliac vasculature, or bypass grafts when performed for one or more of the following indications:

• confirm a suspicion of an abdominal or iliac aneurysm raised by a physical examination or noted as an incidental finding on another radiological examination. The physical examination usually reveals a palpable, pulsatile and nontender abdominal mass;

• monitor the progression of an abdominal aortic aneurysm. It is usually expected that monitoring occurs approximately every six (6) months;

• evaluate patients presenting with signs and symptoms of a thoracic aneurysm. The symptoms usually associated with a thoracic aneurysm are substernal chest pain, back or neck pain described as deep and aching or throbbing as well as symptoms due to pressure on the trachea (dyspnea, stridor, a brassy cough), the esophagus (dysphagia), the laryngeal nerve (hoarseness), or superior vena cava (edema in neck and arms, distended neck veins);

• evaluate patients presenting with signs and symptoms of an abdominal aneurysm. The symptoms usually associated with an abdominal aneurysm are constant pain located in the midabdomen, lumbar region or pelvis which can be severe and may be described as having a boring quality. A leaking aneurysm is characterized by lower back pain, whereas, acute pain and hypotension usually occur with rupture;

• evaluate a patient presenting with signs and symptoms suggestive of an aortic dissection. A patient with an aortic dissection has symptoms such as a sudden onset of severe, continuous tearing or crushing pain in the chest that radiates to the back and is generally unaccompanied by EKG evidence of a myocardial infarction. On physical examination, the patient is agitated, has a murmur of aortic regurgitation.

IV. Visceral Vascular Studies (93975, 93976, 93978, 93979)

Indications:

This procedure is indicated in the evaluation and/or management of vascular disease involving vessels of the abdominal, pelvic, scrotal contents, and/or retroperitoneal organs.

Limitations:

Duplex scanning in the evaluation of an abdominal aortic aneurysm is of limited value unless there is a pulsatile abdominal mass and signs and symptoms of peripheral vascular disease are present. Follow-up of an abdominal aneurysm on a periodic basis using abdominal ultrasound rather than visceral vascular studies to determine growth and potential need for intervention is allowed.

Vascular studies are not the initial diagnostic modality for the evaluation of abdominal pain/tenderness. There must be a high index of suspicion that the pain is caused by a vascular disorder, such as mesentery ischemia. Noninvasive vascular studies are medically necessary only if the outcome will potentially impact the clinical course of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of noninvasive studies, noninvasive vascular procedures are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.

93926 Lower extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93930 Upper extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93931 Upper extremity study Ultrasound General Non- advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93970

ULTRASOUND VENOUS DOPPLER

EXTREMETRIES Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93971 Extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider.

These are sometimes billed with a related radiology code that would hit copay. Yes 93975 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93976 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93978 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes

Florida Medicare may provide coverage for duplex scanning of arterial inflow and venous outflow of abdominal, pelvic, and/or retroperitoneal organs when performed for the following indications:

• To evaluate patients presenting with signs or symptoms such as epigastric or periumbilical postprandial pains that last for 1-3 hours and/or with associated weight loss resulting from decreased oral intake which may indicate chronic intestinal ischemia.

• To evaluate patients presenting with an acute onset of crampy or steady epigastric and periumbilical abdominal pain combined with minimal or no findings on abdominal examination and a high leukocyte count to rule out acute intestinal ischemia.

• To evaluate a patient who has sustained trauma to the abdominal, pelvic and/or retroperitoneal area resulting in a possible injury to the arterial inflow and/or venous outflow of the abdominal, pelvic and/or retroperitoneal organs.

• To evaluate a suspicion of an aneurysm of the renal artery or other visceral artery based on a patients signs and symptoms of abdominal pain or noted as an incidental finding on another radiological examination.

• To evaluate a hypertensive patient who has failed first line antihypertensive drug therapy in order to rule out renovascular disease such as renal artery stenosis, renal arteriovenous fistula, or renal aneurysm as a cause for the uncontrolled hypertension.

• To evaluate a patient with signs and symptoms of portal hypertension. These may include abdominaldiscomfort and distention, abdominal collaterals (caput medusae), abdominal bruit, ascites, encephalopathy, esophageal varices, splenomegaly, etc.

• To evaluate patients suspected of an embolism, thrombosis, hemorrhage or infarction of the portal vein, renal vein and/or renal artery. These patients may present with many different symptoms such as abdominal discomfort, hematuria, cardiac failure, diastolic hypertension, jaundice, fatigue, weakness, malaise, etc.

• To confirm a suspicion of an abdominal or iliac aneurysm raised by a physical examination or noted as an incidental finding on another radiological examination. The physical examination usually reveals a palpable, pulsatile and nontender abdominal mass.

• To monitor the progression of an abdominal aortic aneurysm. It is usually expected that monitoring occurs approximately every six (6) months.

• To evaluate patients presenting with signs and symptoms of a thoracic aneurysm. The symptoms usually associated with a thoracic aneurysm are substernal chest pain, back or neck pain described as deep and aching or throbbing as well as symptoms due to pressure on the trachea (dyspnea, stridor, a brassy cough), the esophagus (dysphagia), the laryngeal nerve (hoarseness), or superior vena cava (edema in necks and arms, distended neck veins).

• To evaluate patients presenting with signs and symptoms of an abdominal aneurysm. The symptoms usually associated with an abdominal aneurysm are constant pain located in the midabdomen, lumbar region or pelvis which can be severe and may be described as having a boring quality. A leaking aneurysm is characterized by lower back pain, whereas, acute pain and hypotension usually occur with rupture.

• To evaluate a patient presenting with signs and symptoms suggestive of an aortic dissection. A patient with an aortic dissection has symptoms such as a sudden onset of severe, continuous tearing or crushing pain in the chest that radiates to the back and is generally unaccompanied by EKG evidence of a myocardial infarction. On physical examination, the patient is agitated, has a murmur of aortic regurgitation, asymmetric diminution of arterial pulses and systolic bruits over the areas where the aortic lumen is narrowed.

• Initial evaluation of a patient presenting with signs and symptoms such as intermittent claudication in the calf muscles, thighs and/or buttocks, rest pain, weakness in legs or feeling of tiredness in the buttocks, etc. which may suggest occlusive disease of the aorta and iliac arteries. The physical examination usually reveals decreased or absent femoral pulses, a bruit over the narrowed artery, and possibly muscle atrophy. If severe occlusive disease exists, the patient will have atrophic changes of the skin, thick nails, coolness of the skin with pallor and cyanosis.

• To evaluate patients suspected of an abdominal or thoracic arterial embolism or thrombosis. These patients usually present with severe pain in one or both lower extremities, numbness, and symmetric weakness of the legs, with absent or severely reduced pulses below the embolism site.

• To evaluate patients presenting with complaints of pain in the calf or thigh, slight swelling in the involved leg, tenderness of the iliac vein, etc. which may suggest phlebitis or thrombophlebitis of the iliac vein or inferior vena cava.
• To evaluate a patient who has sustained trauma to thechest wall and/or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

• To assess the continued patency of both native venous and prosthetic arterial grafts following surgical intervention. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

• To monitor the sites of various percutaneous interventions, including, but not limited to angioplasty, thrombolysis/thrombectomy, atherectomy, or stent placement. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

Note: Duplex testing should be reserved for specific indications for which the precise anatomic information obtained by this technique is likely to be useful.

Therefore, it would be rare to see duplex scanning being performed for conditions in which another diagnostic test is recommended (e.g., an aortic dissection is better diagnosed with a chest X-ray, transesophageal echocardiogram or aortography)

AMA

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